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Rob Oblender BISC605 Fall 2013 Exam 3. Please answer every question concisely.

Points will be deducted for lengthy answers. Please use the space provided. 1. A 56 y.o. male reports to the Nurse Managed Health Center complaining of fatigue & shortness of breath. The shortness of breath gets much worse with any exertion. There is a history of respiratory infections. The patient also has a chronic cough, which is worse in the AM. The patient worked for 18 years in a car manufacturing plant; he was laid off 6 years ago. The patient has smoked cigarettes since he was 15 y.o. He averages about 1 pack of cigarettes a day. VS: T 37.1 C, P 74 bpm, R 26 breaths per minute, BP 122/84 mmHG, BMI 27.8 PE: respiratory distress (mild): elevated respiratory rate along with shallow breaths. End expiratory wheeze on auscultation. Lungs appear normal to percussion. Lab studies: Pulmonary function tests: FEV1 was 69% of predicted and peak expiratory flow was 59% of predicted. FVC was 89% of predicted. Chest radiograph was normal. Arterial Blood Gases: PO2 75, PCO2 42, pH 7.31 A. What is the diagnosis? (6 pts) Chronic Obstructive Pulmonary Disease (COPD) 2 B. What is driving respiration? Does the main controller of respiration change as this disease progresses? Briefly explain. (6 pts) Chemoreceptors respond to changes in blood pH (CO2 concentration) which controls respiration. 2 Yes. Hypoxic drive, or low oxygen levels, eventually takes over control. 2 C. His physician tells him he will benefit from breathing exercises. What breathing exercise(s) do you think will benefit this patient? (6 pts) Pursed lip breathing slows exhalation and breathing rate, introduces new air to lungs. 2 Diaphragmatic breathing (belly breathing) decreases effort needed to breathe, strengthens diaphragm, and decreases bodys oxygen demand. 2 D. He is told by a friend that with his condition he should take it easy and not exercise. Is this good advice? Very briefly explain? (6 pts) No. Light exercise can help improve respiration problems. Intense exercise may cause dizziness and nausea, as well as other things. 2 2. Infants with hypoplastic left heart syndrome have open-heart surgery soon after birth. Describe the flow of blood through the heart before (10 pts) and after (10 pts) the stage 1 (Norwood) procedure. Be sure to state how the lungs are supplied with blood before and after the surgery. Do not answer this in paragraph form, rather, answer with a bullet list. For example, if this were a normal circulation, the bullet list might be:

Rob Oblender BISC605 Fall 2013 -superior / interior vena cava -right atrium -tricuspid value -right ventricle -pulmonary artery -etc. Before: Superior/inferior vena cava Right atrium Tricuspid valve Right ventricle Pulmonary valve Pulmonary arteries (left and right) Lungs Pulmonary veins Left atrium Bicuspid valve Undersized left ventricle Aortic valve Aorta Systemic circulation After: Superior/inferior vena cava Right atrium Tricuspid valve Right ventricle Pulmonary valve Pulmonary artery (NOT left and right) Aorta (connect to pulmonary artery by patch) Shunt / systemic circulation Subclavian artery Right pulmonary artery Lungs Right pulmonary vein left atrium Foramen ovale Right atrium *repeat1 3. A 58 y.o. male reports to the clinic that is located on a mountain peak (resort area for skiers). The altitude is approximately 14,250 feet. He reports a headache, dizziness, dyspnea, and he is not able to sleep. He also reports that his breathing is very rapid,

Rob Oblender BISC605 Fall 2013 especially when he is going up steps, but also when he is sitting down. This individual reports that he arrived at the resort yesterday. His ski vacation is scheduled for 1 week. The patients temperature is 37 degrees C. Pulse is 82 beats per minute. Respiration rate is 42 breaths per minute. Blood pressure is 108/78 mmHg. His BMI is 26.5. The patient has a rapid and shallow breathing pattern, and his fingernails show some cyanosis. Laboratory studies show end tidal PO2 to be 60 mmHg and PCO2 to be 30 mmHg. Pulse oximetry is 70% saturated. A. List the diagnosis? (6 pts) Acute Mountain Sickness 3 B. What life-threatening condition(s) can this diagnosis lead to? (just list) (6 pts) Coma3 Pulmonary edema3 Cerebral edema3 C. What is the main cause of the symptoms? (6 pts) Reduced air pressure and low oxygen levels3 D. What is the cause of the headache? (6 pts) vasodilation of cerebral blood vessels caused by hypoxia, resulting in greater blood flow and greater capillary pressure3 E. What is the drug treatment? What is the mechanism of action of this drug? (6 pts) Acetazolamide (Diamox). It is a mild diuretic that stimulates the kidneys to secrete more bicarbonate in the urine, making the blood more acidic. This change in pH signals the respiratory center to increase the depth and frequency of respiration, which speeds up the natural acclimation process3 4. A 49-year-old patient with a body mass index of 38 reports daytime drowsiness. The spouse reports that the patient snores loudly and appears to stop breathing throughout the night. After 30 or more seconds of not breathing, the patient then takes a labored breath. This pattern repeats itself throughout the night. A. What is this condition called? List some of the contributing (i.e., risk) factors. (7 pts) Obstructive Sleep Apnea (OSA) 4 Obesity Age (over 40) Gender (males more susceptible) Family history Nasal obstruction 4 B. What are the autonomic and cardiovascular effects of not breathing for more than 30 seconds? (7 pts)

Rob Oblender BISC605 Fall 2013 Lack of breath for that long causes hypoxia, which effectively lowers blood pH, reduces heart rate, and can cause tissue and nerve damage. 4

C. Does this patient have an increased risk of hypertension? Why? (8 pts) Yes. OSA can cause elevated blood pressure during sleep, similar to how hypertension causes high blood pressure. Autonomic dysfunction, caused by OSA, leads to elevated levels of vasoconstrictors versus vasodilators. Since this patient is also overweight, he is at an even greater risk for hypertension. 4

Rob Oblender BISC605 Fall 2013 References 1) 2) 3) 4) http://www.youtube.com/watch?v=n1fgF7cd2wc http://www.mayoclinic.com/health/copd/DS00916 http://www.nlm.nih.gov/medlineplus/ency/article/000133.htm http://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea